ONCOLOGY.
No. 1
REVIEW ARTICLE
Management of Pain in the Older Person With Cancer Part 1: Pathophysiology, Pharmacokinetics, and Assessment
Your Older Patient
By Marvin Omar Delgado-Guay, MD1, Eduardo Bruera, MD2 |
January 1, 2008
1Research Fellow
2Professor and Chair, Palliative Care and Rehabilitation Medicine, The University of Texas M. D. Anderson Cancer Center, Houston, Texas
The elderly need an individualized approach to pain assessment that should take into account not only tumor histology and stage, but also the patient's medical, psychosocial, and spiritual conditions. Appropriate multidimensional geriatric assessment[2,29] should include the medical history and tumor staging, physical examination, performance status (Karnofsky Performance Scale or Eastern Cooperative Oncologic Group Scale),[30-33] Activities of Daily Living (according to the 6-item ADL scale of Katz et al[34] or the 8-item instrumental ADL scale of Lawton et al[35]), the physical performance test,[36] evaluation of comorbid conditions,[37,38] affective status (especially the presence of depression and/or anxiety),[39] cognitive status (using the Mini-Mental State Examination [MMSE]),[40] and evaluation for geriatric syndromes such as dementia, delirium, failure to thrive, neglect or abuse, falls, and incontinence. Table 1 shows a multidimensional approach to older cancer patients with pain.
One of the greatest barriers to cancer pain assessment in elderly patients is delirium. Defined as a transient and potentially reversible disorder of cognition and attention, delirium frequently complicates care at the end of life. In general, the etiology of delirium is multifactorial, especially in patients with advanced cancer and the elderly.[1,42-46] Delirium causes significant distress; it impedes communication with family members and caregivers at a time when it is often most desired.[44,45]
Prompt recognition of delirium is important not only because delirium can make the reliable reporting of symptoms difficult for patients, who frequently present with disinhibition,[44,45] and renders them unable to participate in decisions about therapeutic interventions, but because patients may benefit from appropriate interventions such as supportive psychotherapy.[44] Some pain behaviors in older patients with cognitive impairment can help the identification of distress in these patients; Figure 2 summarizes these behaviors.
If delirium is not recognized, not only family members but also health-care providers may misinterpret agitation as a sign of pain, resulting in escalated doses of opioids that can produce toxicity and complicate the delirium. To facilitate the diagnosis of delirium and impose relatively little burden on patients, instruments with adequate psychometric properties have been created, such as the Memorial Delirium Assessment Scale (MDAS),[1,41-43] the MMSE,[40] and the Confusion Assessment Method (CAM).[46]
The MDAS, a validated tool used in our palliative care practice, was designed to measure the severity of delirium and therefore captures behavioral manifestations as well as cognitive deficits.[42] This instrument measures relative impairment in awareness, orientation, short-term memory, digit span, attention capacity, organizational thinking, psychomotor activity, and sleep-wake cycle, as well as perceptual disturbances and delusions. Items are rated from 0 (none) to 3 (severe), depending on the level of impairment, with a maximum possible score of 30. The higher the score, the more severe the delirium. A total MDAS score of 7 out of 30 yields the highest sensitivity (98%) and specificity (96%) for the diagnosis of delirium.[41]
Cognitive Impairment
It is important to mention that frail elderly cancer patients with baseline cognitive impairment or with dementia may develop delirium secondary to the presence of pain, thus appropriate evaluation of the possible sources of pain, such as fractures, constipation, bowel obstruction, and/or urinary retention, must be performed, and therapy should be oriented to treat the underlying cause and other symptoms accompanying the delirium.
Cognitive decline can be a barrier to proper pain assessment, although reliable pain measurements can still be obtained from persons with mild or moderate cognitive impairment.[8,47] Pautex et al showed that 61% of 129 severely demented patients (mean age = 83.7 years) were able to demonstrate comprehension of at least one of the three self-assessment tools for pain evaluation (verbal, horizontal visual, and faces pain scales). A better comprehension rate was noted for the verbal and faces pain scales than for the horizontal visual scale. In addition, the investigators suggested that the observational rating scale may underestimate the severity of pain when compared with self-assessment scales.[48]
As a part of the history taken for an older cancer patient with pain, it is important to ask for the characteristics and intensity of pain and about any variation in pain with change of movement or time of day, and how the pain affects the patient's Activities of Daily Living.[7,8]
The Edmonton Symptom Assessment Scale (ESAS) is an important tool for evaluating symptoms that an older cancer patient has experienced over the past 24 hours.[49-51] This scale assesses nine common symptoms (pain, fatigue, nausea, depression, anxiety, drowsiness, shortness of breath, appetite, and sleep problems) and feeling of well-being. The patient rates the intensity of each symptom on a 0 to 10 numerical scale, with 0 representing "no symptom" and 10 representing the "worst possible symptom." The ESAS, which is free and available in English and 14 other languages, has been found to be reliable in cancer patients and to have internal consistency, criterion validity, and concurrent validity.[52] Its ease of use and visual representation make it an effective and practical bedside tool that allows the health-care provider to track symptoms over time with regard to intensity, duration, and responsiveness to therapy. The symptoms identified in the ESAS help us to better understand the factors related to the expression of pain.
Another important tool to use in older cancer patients with pain is the CAGE questionnaire,[53,54] which screens for alcohol(Drug information on alcohol) abuse at any period of life. This simple tool consists of four questions: Have you ever felt that you should Cut down on your drinking? Have you been Annoyed by people criticizing your drinking? Have you ever felt bad or Guilty about your drinking? Have you ever had a drink to get rid of a hangover, ie, an Eye-opener?
An abnormal score, defined as two or more positive answers to the four questions, has been shown to have prognostic value in opioid management in patients with cancer who experience pain. The CAGE questionnaire help us to identify patients who are at high risk of developing chemical coping and subsequently high risk of opioid dose escalation and overall increased risk of opioid-induced toxicity. Approximately 20% of cancer patients have a positive CAGE questionnaire.[53,54]
Financial Disclosure: The authors have no significant financial interest or other relationship with the manufacturers of any products or providers of any service mentioned in this article.
Management of Pain in the Older Person With Cancer
1. Yennurajalingam S, Braiteh F, Bruera E: Pain and terminal delirium research in the elderly. Clin Geriatr Med 21:93-119, 2005.
2. Basso U, Monfardinin S: Multidimensional geriatric evaluation in elderly cancer patients: A practical approach. Eur J Cancer Care 13:424-433, 2004.
3. Mercadante S, Arcuri E: Pharmacological management of cancer pain in the elderly. Drugs Aging 24:761-776, 2007.
4. Dalal S, Del Fabbro E, Bruera E: Symptom control in palliative care—Part 1: Oncology as a paradigmatic example. J Palliat Med 9:391-408, 2006.
5. Stein W, Miech R: Cancer pain in the elderly hospice patient. J Pain Symptom Manage 8:474-482, 1993.
6. World Health Organization: Cancer Pain Relief. Geneva, WHO, 1986.
7. Goldstein N, Morrison S: Treatment of pain in older patients. Crit Rev Oncol Hematol 54:157-164, 2005.
8. Balducci L: Management of cancer pain in geriatric patients. J Support Oncol 1:175-191, 2003.
9. Fine P: Pharmacological management of persistent pain in older patients. Clin J Pain 20:220-226, 2004.
10. Goodlin S, Winzeleberg GS, Teno JM, et al: Death in the hospital. Arch Intern Med 158:1570-1572, 1998.
11. Cleeland CS, Gonin R, Hartfield AK, et al: Pain and its treatment in outpatients with metastatic cancer. N Engl J Med 330:592-596, 1994.
12. Cohen-Mansfield J: The adequacy of minimum data set assessment of pain in cognitively impaired nursing home residents. J Pain Symptom Manage 27:343-351, 2004.
13. Portenoy R, Lesage P: Management of cancer pain. Lancet 353:1695-1700, 1999.
14. Urch C: The pathophysiology of cancer-induced bone pain: Current understanding. Palliat Med 18:267-274, 2004.
15. Bruera E: Research into symptoms other than pain, in Doyle D, Hanks GW, MacDonald N (eds): Oxford Textbook of Palliative Medicine, ed 3, pp 179-185. New York, Oxford University Press, 1998.
16. Hopwood P, Stephens RJ: Depression in patients with lung cancer: prevalence and risk factors derived from quality-of-life data. J Clin Oncol 18:893-903, 2000.
17. Bruera E, Kim HN: Cancer pain. JAMA 290:2476-2479, 2003.
18. Gibson SJ, Helme RD: Age-related differences in pain perception and reports. Clin Geriatr Med 17:334-351, 2001.
19. Edgards R, Fillingim R, Ness T: Age-related differences in endogenous pain modulation: A comparison of diffuse noxious inhibitory controls in healthy older and younger adults. Pain 101:155-165, 2003.
20. Davis MP, Srivastava M: Demographics, assessment and management of pain in the elderly. Drugs Aging 20:23-57, 2003.
21. Farrell M, Gibson S: Age interacts with stimulus frequency in the temporal summation of pain. Pain Med 8:514-520, 2007.
22. Clinch D, Banjeree AK, Ostik G: Absence of abdominal pain in elderly patients with peptic ulcer. Age Ageing 13:120-126, 1984.
23. Wroblewski M, Mikulowshi P: Peritonitis in geriatric inpatient. Age Ageing 20:90-102, 1992.
24. Landi F, Onder G, Cesari M, et al: Pain occurs daily, remains untreated among elderly patients in community settings. Arch Intern Med 161:2721-2724, 2001.
25. Curless R, French JM, Williams GV, et al: Colorectal cancer: Do elderly patients present differently? Age Ageing 23:102-108, 1994.
26. Viganó A, Bruera E, Suarez-Almazor ME: Age, pain intensity, and opioid dose in patients with advanced cancer. Cancer 83:1244-1250, 1998.
27. Fuse PG: Opioid analgesic drugs in older people. Clin Geriatr Med 17:479-485, 2001.
28. Repetto L, Balducci L: A case for geriatric oncology. Lancet Oncol 3:289-297, 2003.
29. Hurria A, Lachs M, Cohen H, et al: Geriatric assessment for oncologists: Rationale and future directions. Crit Rev Oncol Hematol 59:211-217, 2006.
30. Coates A, Gebski V, Signorini D, et al: Prognostic values of quality of life scores during chemotherapy for advanced breast cancer. J Clin Oncol 10:1833-1838, 1992.
31. Miller F: Predicting survival in the advanced cancer patient. Henry Ford Hosp Med 391:81-84, 1991.
32. Schag C, Heinrich R, Ganz P: Karnofsky performance status revisited: Reliability validity and guidelines. J Clin Oncol 2:187-193, 1984.
33. Yates J, Chalmer B, McKegner F: Evaluation of patients with advanced cancer using the Karnofsky performance status. Cancer 45:2220-2224, 1980.
34. Katz S, Ford AB, Moskowitz RW, et al: Studies of illness in the aged. The index of ADL: A standardized measure of biological and psychological function. JAMA 185:914-919, 1963.
35. Lawton MP, Brody EM: Assessment of older people: self-maintaining and instrumental activities of daily living. Gerontologist 9:179-186, 1969.
36. Reuben DB, Siu A: An objective measure of physical function of elderly out-patients. The physical performance test. J Am Geriatr Soc 38:1105-1112, 1990.
37. Charlson M, Pompei P, Ales K, et al: A new method of classifying prognostic comorbidity in longitudinal studies: Development and validation. J Chron Dis 40:373-383, 1987.
38. Miller M, Paradis C, Houck P, et al: Rating chronic medical illness burden in gero-psychiatric practice and research: Application of the Cumulative Illness Rating Scale. Psychiatry Res 41:237-248, 1992.
39. Hickie C, Snowdon J: Depression scales for the elderly: GDS. Clin Gerontol 6:51-53, 1987.
40. Folstein M, Folstein S, McMugh P: Mini mental state: A practical method for grading the cognitive state of patients for the clinician. J Psych Res 12:219-226, 1975.
41. Lawlor P, Nekolaichuk C, Gagnon B, et al: Clinical utility, factor analysis, and further validation of the Memorial Delirium Assessment Scale in patients with advanced cancer. Cancer 88:2859-2867, 2000.
42. Centeno C, Sanz A, Bruera E: Delirium in advanced cancer patients. Palliat Med 18:184-194, 2004.
43. Rooij SE, Schuurmans MJ, van dal Mast RC, et al: Clinical subtypes of delirium and their relevance for daily clinical practice: A systematic review. Int J Geriatr Psychiatry 20:609-615, 2005.
44. Lawlor P, Fainsinger R, Bruera E: Delirium at the end of life. Critical issues in clinical practice and research. JAMA 284:2427-2429, 2000.
45. Lawlor P, Gagnon B, Mancini I, et al: Occurrence, causes, and outcome of delirium in advanced cancer patients: A prospective study. Arch Intern Med 160:786-794, 2000.
46. Inouye S, van Dyck C, Alessi C, et al: Clarifying confusion: The confusion assessment method: A new method for detection of delirium. Ann Intern Med 113:941-948, 1990.
47. Herr KA, Garand L: Assessment and measurement of pain in older adults. Clin Geriatr Med 17:457-478, 2001.
48. Pautex S, Michon A, Guedira M, et al: Pain in severe dementia: Self-assessment or observational scales? J Am Geriatr Soc 56:1040-1045, 2006.
49. Bruera E, Kuehn N, Miller MJ, Selmser P, et al: The Edmonton Symptom Assessment System (ESAS): A simple method for the assessment of palliative care patients. J Palliat Care 7:6-9, 1991.
50. Porzio G, Ricevuto E, Aielli F, et al: The Supportive Care Task Force at the University of L'Aquila: 2-years experience. Support Care Cancer 13:351-355, 2005.
51. Stromgren AS, Groenvold M, Peterson MA, et al: Pain characteristics and treatment outcome for advanced cancer patients during the first week of specialized palliative care. J Pain Symptom Manage 27:104-113, 2004.
52. Chang V, Hwang S, Feuerman M: Validation of the Edmonton Symptom Assessment Scale. Cancer 88:2164-2171, 2000.
53. Bruera E, Moyano J, Seifert L, et al: The frequency of alcoholism among patients with pain due to terminal cancer. J Pain Symptom Manage 10:599-603, 1995.
54. Bruera E, Watanabe S: New developments in the assessment of pain in cancer patients. Support Care Cancer 2:312-318, 1994.
Comprehensive Assessment of Pain in Older Cancer Patients
Common Behavioral Expressions of Pain in Older Cancer Patients With Cognitive Impairment
